Suspected

Cows Milk Allergy (CMA) in the 1st Year of Life TB/TB/AF/

NS/CV/JW
- having taken an Allergy-focused Clinical History Oct 2013


Mild to Moderate
Severe Mild to Moderate
Non-IgE-mediated CMA IgE-mediated CMA
Non-IgE-mediated CMA
Delayed Onset Symptoms Acute Onset Symptoms
Delayed Onset Symptoms

Mostly 2-72 hrs. a/er inges4on of CMP

Mostly within minutes of inges4on of CMP

Mostly 2-72 hrs. a/er inges4on of CMP

Formula fed, exclusively breast fed Mostly formula fed or at onset of mixed feeding
Formula fed, exclusively breast fed
or at onset of mixed feeding
or at onset of mixed feeding

One or more of these symptoms:

One, or o/en, more than one Severe persis4ng symptoms of one or more of:

Skin

of these symptoms:
Gastrointes=nal Acute pruritus, erythema, ur4caria,
Gastrointes=nal

Diarrhoea, vomi4ng, abdominal pain, food refusal angioedema

Colic Acute aring of atopic eczema
or food aversion, signicant blood and/or mucus
Vomi4ng - Reux - GORD

in stools, irregular or uncomfortable stools. Gastrointes=nal

Food refusal or aversion +/- Faltering growth Vomi4ng, diarrhoea, abdominal pain/colic
Loose or frequent stools

Perianal redness Skin Respiratory

Cons4pa4on Severe Atopic Eczema +/- Faltering Growth Acute rhini4s and/or conjunc4vi4s
Abdominal discomfort,
Blood and/or mucus in stools in an

otherwise well infant
Cows Milk Free Diet
Severe

Cows Milk Free Diet

Extensively Hydrolysed Formula - eHF
Skin Amino Acid Formula IgE CMA (Ini4al choice, but some infants may then need an
AAF Amino Acid Formula - AAF trial if not se^ling)
Pruritus, erythema

ANAPHYLAXIS

Signicant atopic eczema Advise breast feeding

Advise breast feeding mother to exclude all CMP from
mother to exclude all CMP Immediate reac4on
her own diet and to take daily Calcium (1000mg) and Vit
Respiratory from her own diet and to with severe respiratory
D (10mcg) supplements
Catarrhal airway symptoms take daily Calcium (1000mg) and/or CVS signs and

symptoms. IgE tes4ng needed.

(usually in combina4on with one and Vitamin D (10mcg)

supplements (Rarely a severe If diagnosis conrmed (which may require a Supervised

or more of the above symptoms ) gastrointes4nal Challenge) Follow-up with serial IgE tes4ng and later

Ensure: presenta4on) planned and Supervised Challenge to test for acquired

Emergency tolerance

Urgent referral to a
Can be managed in

paediatrician with an Treatment Diete4c referral required

Primary Care interest in allergy

and If competencies to arrange and interpret tes=ng are not

See
Urgent diete4c referral Admission in place - early referral to a paediatrician with an
Management Algorithm

interest in allergy - advised

 Primary Care Management of Mild to Moderate Non-IgE CMA TB/TB/AF/
NS/CV/JW
(No ini4al IgE Skin Prick Tests or Serum Specic IgE Assays necessary) Oct 2013

Exclusively Breast-Fed Formula-Fed or Mixed Feeding (Breast and Formula)
Strict Cows Milk Protein free Diet
Strict Exclusion of cows milk containing foods from Maternal Diet

Formula-fed - Trial of an Extensively Hydrolysed Formula (eHF) in infant

Maternal supplements of Calcium (1000mg) and Vitamin D (10mcg) daily

Mixed feeding - Trial of a cows milk free Maternal Diet

Refer to die44an

With eHF top-ups for infant if needed

If CMA - most symptoms will se^le well within the agreed 2-4 week Elimina4on Diet Refer to die44an

No Improvement Improvement - need to conrm Diagnosis If CMA - most symptoms will se^le well within the agreed 2-4 week Elimina4on Diet

Improvement - need to conrm Diagnosis No Improvement

Home Challenge: Mum to revert to normal Perform Home Challenge using cows milk

CMA s=ll suspected: diet containing cows milk containing foods over CMA s=ll suspected:
formula

Need to consider other period of one week (to be done between 2-4 weeks (to be done between 2-4 weeks of star4ng Refer to a paediatrician with
maternal foods e.g. egg of star4ng Elimina4on Diet) Elimina4on Diet) an interest in allergy
Refer to a paediatrician with an Consider a trial of AAF

interest in allergy
No return of Symptoms: Symptoms Symptoms No return of Symptoms:

NOT CMA return return NOT CMA
CMA no longer suspected: CMA no longer suspected:

Exclude cows milk containing foods

Return to usual maternal diet Unrestricted diet again

Consider referral to general from maternal diet again. Return to the eHF again. Consider referral to general
paediatricians if symptoms Symptoms If symptoms seWle: Symptoms
do not do not paediatricians if symptoms
persist CMA NOW CONFIRMED If symptoms seWle: persist
seWle seWle
CMA NOW CONFIRMED

If top-up formula feeds needed:

Use an AAF

Cows milk free diet un4l 9-12 months of age and for at least 6 months with support of die44an
A planned Reintroduc=on or Supervised Challenge is then needed to determine if tolerance has been achieved
Performing a Reintroduc4on vs. a Supervised Challenge is dependent on the answer to the ques4on:

Does the child have Current Eczema or ANY history at ANY =me of acute onset symptoms ?

No Current Eczema History of acute onset symptoms at any =me

And no history at any stage of acute onset symptoms Current Eczema Serum Specic IgE or Skin Prick Test needed

(No need to check Serum Specic IgE or perform Skin Prick Test)
Nega=ve Posi=ve
Reintroduc=on at Home using a MILK LADDER Check Serum Specic IgE or
To test for Tolerance Liaise with local Allergy Service Re: Challenge (or tests not available)
Skin Prick Test to cows milk

And s=ll no history at any stage of acute onset symptoms Nega=ve Posi=ve Refer to a paediatrician with an interest in allergy
Reintroduc=on at Home - using a MILK LADDER
To test for Tolerance (A Supervised Challenge may be needed)